We have to get smarter about how we try to improve medical care. I believe the next phase of quality improvement will be a move away from homogenizing care and toward personalizing it, perhaps with the help of genomic research. Neither the old approach, in which seemingly every patient was treated differently, nor the new one, where we try to treat them all the same, has worked well. Medicine needs another way.

A great idea except genomic medicine has almost no evidence supporting it. We have excelled at uncovering the genetic components of diseases and physiology. Unfortunately, we have not excelled (so far) at applying that knowledge to changing the practice of medicine.

A quick example, we know that opioids are metabolized with the help of an enzyme encoded by the CYP2D6 gene. We also know that this gene is highly variable in humans. We know how to detect this variability using genetic testing. We do not know what to do with this information [1]. I could have a patient’s CYP2D6 profile in my hands but I would not have a precise estimate of how I should adjust their morphine dosing…because no such studies have been done.

Genomic medicine is likely part of the answer, but we are going to need the translational research first and then guidelines on what to do with that research.

…other than to tell people at the extremes (very poor metabolizers and very rapid metabolizers) they should likely avoid opioids all together. ↩